Provider Demographics
NPI:1770509267
Name:PREVENTIVE HEALTH CENTER INC
Entity Type:Organization
Organization Name:PREVENTIVE HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISSA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JEAN-PIERRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-458-2559
Mailing Address - Street 1:2500 E HALLANDALE BEACH BLVD
Mailing Address - Street 2:SUITE 406
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-4834
Mailing Address - Country:US
Mailing Address - Phone:954-458-2559
Mailing Address - Fax:954-454-3833
Practice Address - Street 1:2500 E HALLANDALE BEACH BLVD
Practice Address - Street 2:SUITE 406
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-4834
Practice Address - Country:US
Practice Address - Phone:954-458-2559
Practice Address - Fax:954-454-3833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85417207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5108Medicare PIN